#MSCOVID19. The tidal wave begins


I have been trying to keep up will my COVID-19 reading in case some gems appear. I owe you a new post to say that I was wrong about the disappearing T cells and now I wonder if there lies the problem for the people geting severe MS. The good news I think is that the MS drugs are not targetting the COVID-19 solution in terms of getting rid of the virus.

Now the trickle is becoming a flood and with 400-500 papers a day, I am being swamped and now you miss the gems because this appears in a sea of mediocrity. Worse of all people are making SH1-up to get a story in this or that paper.

For example, yesterday, I read in an Impact factor 10 paper about a consortium set up to work on Neutrophils in COVID 19. They did some fancy work and suggests it cures the problem of the neutrophils in COVID-19…..Yeah. However I looked at their pictures of neutrophils in the the lung and couldn’t see any. To me mind they were all macrophage/lymphocyte like and then I read their references where they say that neutrophils are important and you translate the Chinese and it says there are very few neutrophils in the lung and then you look in the other paper they use to support their argument and it says there are no neutrophils in the lungs, unless there is a secondary infection……..Argh my head is exploding.

So the trickle that starts today is now the beginning of the flood, we are all writing reviews , but they will be way out of date by the time they arrive.

Digital triage for people with multiple sclerosis in the age of COVID-19 pandemic. Bonavita S, Tedeschi G, Atreja A, Lavorgna L.Neurol Sci. 2020 Apr 17. doi: 10.1007/s10072-020-04391-9. [Epub ahead of print]PMID: 32303856. We propose a possible approach for the remote monitoring of infection risk in people with multiple sclerosis, especially those on immunosuppressant drugs, during COVID-19 pandemic. We developed a digital triage tool to be sent to patients to quickly identify people with high risk of COVID-19 infection. This tool will also limit unnecessary accesses to the MS centers reducing the risk of spreading the infection.

Approaches to reduce the risk for pwMS as well as the community may include the following steps:

  1. 1.Prior to engagement with the health system (outreach)
  1. (a)Ensure pwMS with scheduled appointments are screened in a non-face-to-face setting.
  2. (b)Pro-actively review population segments deemed high risk (e.g., immunocompromised).
    1. 2.During engagement with existing triage pathways (triage)
  3. (a)Enhance triage to include automated next site of care decision-making via chatbot; telehealth intervention for high-risk patients; assignment of patients for ongoing surveillance via phone, text, or email surveys; and rapid distribution of up-to-date information from a customized knowledge base.
    1. 3.Post-engagement (surveillance)
  4. (a)Automatically ensure follow-up and ongoing surveillance of vulnerable patients.
  5. (b)Ensure testing sensitivity and follow-up by enabling automatic enrollment of patients with negative lab results for monitoring.
    1. 4.Approaches to decrease the burden for health care workers and mitigate their risk
  6. (a)Empower improved handling of inbound volume
  7. (b)Reduce unnecessary visits and increase efficiency of triage protocols by proactively engaging patients through customized digital programs and care pathways.

What do you think?

Multiple sclerosis and the risk of infection: considerations in the threat of the novel coronavirus, COVID-19/SARS-CoV-2. Willis MD, Robertson NP.J Neurol. 2020 Apr 17. doi: 10.1007/s00415-020-09822-3. [Epub ahead of print]

This study aimed to characterise the infection risk of patients with MS compared with a cohort of patients without MS.

(1) The authors utilised two large databases, the United States Department of Defense (US-DOD) health care system and the United Kingdom’s Clinical Practice Research Datalink GOLD (UK-CPRD). The US-DOD is composed of data from members of the US-DOD, retirees and dependents. The UK-CPRD is a large, prospectively collected medical record database from over 500 general practices.

Patients with a first diagnosis of MS were identified between the years 2001 and 2016 (UK-CPRD, n = 6932) and 2004 and 2017 (US-DOD, n = 8695). MS patients were matched to patients without MS based on age, sex, date of MS diagnosis/matched date, and location (US-DOD; 86,934, UK-CPRD 68,526)

The incidence of infection was higher in MS patients compared with non-MS patients: US-DOD (IRR 1.76; 95% CI 1.72–1.80) and UK-CPRD (IRR 1.25; 95% CI 1.21–1.29). Compared to patients without MS, the rate of infections causing hospitalisation in MS patients was higher in both databases (US-DOD IRR 2.43; 95% CI 2.23–2.63 and UK-CPRD IRR 2.00; 95% CI 1.84–2.17).

However, Pneumonia and influenza risk were increased in MS patients in the US-DOD, but not the UK-CPRD  (This suggests that there may be not that must extra risk for a lung infection..in the UK). Viral infections were slightly increased in the US-DOD cohort, but not the UK-CPRD. Respiratory and throat infections rate were slightly elevated in the MS group

(2) Infection risks among patients with multiple sclerosis treated with fingolimod, natalizumab, rituximab, and injectable therapies.

A total of 8600 treatment episodes were included from a total of 6421 patients (female 71.9%; 2217 initiations of IFN-β and GA, 1535 fingolimod, 1588 natalizumab, and 3260 rituximab). The mean time (years) receiving DMTs was as follows: IFN-β and GA, 2.1; fingolimod, 7; natalizumab, 2.5; rituximab, 2.0. The crude serious infection incidence rate was higher across all MS patients compared to the general population.

This large cohort study provides further support that patients with MS being treated with DMTs are at a generally increased risk of infection, with rituximab associated with the highest rate of serious infections.

(3) They investigated the association between MS DMTs and risk of infections in a population-based retrospective cohort study. The primary study outcome was the hazard of infections, based on physician claims with secondary outcomes related to the risk of infection-related hospital admissions and individual infections.

DMTs were grouped into first generation (IFN-β or GA) or second generation (natalizumab, fingolimod, or dimethyl fumarate). Of note, no patients were taking teriflunomide, alemtuzumab or the generic beta-interferon-1b (Extavia).

In this study, exposure to a second generation DMT was associated with an increase in the risk of infection, particularly with regard to natalizumab. First generation DMTs were not associated with an increased risk. Of note, IFN-β was associated with a lower risk of pneumonia, which the authors speculate could be due to its anti-viral effect. The reason for the increased risk of upper respiratory tract infections with second generation DMTs, and in particular natalizumab is unknown. 

They you go now I have to update my f-ing review cos it is missing stuff

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  • I absolutely agree. There are lots of papers that are utter garbage and unfortunately getting published in ‘premier’ journals with journal impact factor (JIF) in the 7-20 range. Anything from China, literally, gets published, or so it seems. There are papers that are published because someone has collected some basic ‘ground truth data’ (for want of better phraseology) on, let us say, 120 patients – they will collect everything from vital signs to about 20 different cytokines/inflammatory markers in serum to CT images of chest to whatever else, collate the data and pump that into a journal. Most journals, hungry for something on CoVID 19 type articles, are publishing at break-neck speed because they do not want to be ‘left behind’. The title may read ‘Compendium of case reports from blah blah blah province of China on CoVID 19’.

    When all this is said and done and silence descends on us all, everyone will be quick to point out that ‘we screwed up because of our enthusiasm to get the word out’ type comments. What else is new ?

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